39 Pump Report 2020F
4 Commonwealth_ of' ', 'el is
Massfkchus
City/Toawn ofups .
System .P*0g. record
Form 4.
DEP has provided this form for use by local Boards of Health. Other fohna map! be used, but the
Information must be substantially the axne as that provided here. Before using this•forrn, check with your
local Board. of Health to determine the form they use. The System PUMPhV Record must be submitted to .
the local Board of Health or other approving authority within U days from the pumping data in
accordance with 810 CMR 15.351.
A. Facility Information
4,
Inwrtant
our 1. System Location:
irxme'ar tile'
comptder. ueeiy Addmw
vay the tet, tr_
to nave your. .
6iWr=do trot Coyfr wn State Zip Code
use the return
' 2. System owner.Nime
° r
amu. ,1 tx r1j
Addrosa ffl ditmnt from wcauc n).
ogrrrown State Zip Cale -
B. Pumping Record����
1. ' D,aW.of in Pum 'r
"• P 9 . para • . �. 49aMkyPurnped:. _
3.. Type:bf•sysiem:. ' P] Cesspaol(s) ', j-�SepticTank ❑ Tight Tank ❑ Grease Trap
❑ Other. (describe):
4. Effluent Tea Fitter present? ❑ Yes .� No If yes, was It clearied7 :❑ Yes- M
5. Condipon. of System: . .
ped BY,
YOM .
7. ��,��tion!ere contents were disposed:
SlpiH NeatHaular. ... Data
Signature of Receiving Fadgq
trorm 4.doo. 0=6 � svatsm Primping necora.• Page 1: of 1